Asset Protection Worksheet

Please fill out the asset protection form below. Once you submit the form one of our attorneys will review the information and have an answer to you within 48 hours.
If you have any questions in the meantime, please contact our office at (315) 793-3622. Thank you.

CONFIDENTIAL – PROTECTED BY ATTORNEY CLIENT PRIVILEGE

General Information

Name(Required)
Spouse Name
(if applicable)
(if applicable)
Address(Required)
Are you or your spouse a veteran?(Required)

Current Information

Trust Planning

You(Required)
Spouse(Required)
Type(Required)

Long-Term Care Insurance

You(Required)
Spouse(Required)

In A Nursing Home?

You(Required)
Spouse(Required)

Your Health

You - Current Health(Required)
Spouse - Current Health(Required)
Have you given away any assets in the last 60 months?(Required)
Do you have children?(Required)
Does your spouse have children?(Required)

Financial Information

Monthly Income (Pension, Social Security, Etc.)

(If n/a, enter 0)

Assets (Current Value) - You or Joint Name

Current Value
Current Value

Assets (Current Value) - Spouse Name

Current Value
Current Value

Assets (Current Value) - Total

Current Value
Current Value

Liabilities/Debts - You or Joint

Liabilities/Debts - Spouse

Liabilities/Debts - Total

Monthly Living Expenses - You or Joint

Monthly Living Expenses - Spouse

Monthly Living Expenses - Total

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